This document outlines the management of hypertensive disorders in pregnancy, including gestational hypertension, preeclampsia, and eclampsia. It defines the conditions and discusses monitoring, treatment with antihypertensives like magnesium sulfate and delivery. Key points covered include diagnosing preeclampsia based on blood pressure and proteinuria levels, treating mild cases with bed rest and severe cases with magnesium sulfate and delivery within 24 hours, and continuing magnesium sulfate for 24 hours postpartum or after the last seizure.

1. Hypertensive Disorder In Pregnancy
•Hypertension in pregnancy is defined as a
diastolic blood pressure of 90mmhg or
high and systolic blood pressure of
140mmhg or more after 20 weeks of
pregnancy in a women with previously
normal blood pressure.
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2. Hypertensive Disorders
of Pregnancy
Pre eclampsia
Eclampsia
HELLP
Syndrome
Gestational
hypertension
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Chronic Hypretension

3. Gestational Hypertension
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Mild:140/90mmhg Severe: 160/110mmof Hg or more

4. •Chronic Hypertension with
superimposed preeclampsia: defined
as proteinuria developing for first
time during pregnancy in a women
with known chronic hypertension
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5. CHRONIC HYPERTENSION DURING
PREGNANCY
• Encourage additional rest
• Determine whether to use BP medicine
• If well controlled on medicine before pregnancy,
continue
• If diastolic BP >110 or systolic >160, treat
• If proteinuria or other signs and symptoms present,
consider superimposed pre-eclampsia
• Drugs of choice in pregnancy: nifedipine (oral),
methyldopa (oral) or in acute situation,in labetolol IV
hydralazine
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6. PRE- ECLAMPSIA:
Mild: Two readings of diastolic blood pressure
90-110 mmHg 4-6 hours apart after 20 weeks
gestation with proteinuria up to 2+
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7. SEVERE PRE- ECLAMPSIA:
Diastolic blood pressure 110 mmHg or more after 20
weeks gestation with proteinuria 3+ or more and may or
may not be associated with
 Headache unrelieved by analgesics
 Blurring of vision
 Oliguria (< 400ml in 24 hours)
 Epigastric pain or pain in right upper quadrant
 Pulmonary edema
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8. MANAGEMENT OF GESTATIONAL
HYPERTENSION
• Monitor blood pressure, urine and fetal condition
• If blood pressure worsens, manage as mild pre-
eclampsia
• If there are signs of severe fetal growth restriction or
fetal compromise, admit woman to hospital for
assessment
• Counsel woman and family about danger signals of
pre-eclampsia and eclampsia
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9. MANAGEMENT OF MILD PRE-ECLAMPSIA AT <37
WEEKS GESTATION
• Monitor blood pressure, urine, reflexes and
fetal condition
• Encourage additional periods of rest
• Encourage woman to eat a normal diet
• Do not give anticonvulsants, antihypertensives
or tranquilizers
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10. MANAGEMENT OF MILD PRE-ECLAMPSIA AT <37
WEEKS GESTATION CONT..
• Admit woman to the hospital if outpatient
follow-up not possible:
• Provide normal diet
• Monitor BP 4 hourly and urine for protein
preferably twice daily.
• Do not give antihypertensives, sedatives or
anticonvulsants unless BP or urine protein increases
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11. MANAGEMENT OF MILD PRE-ECLAMPSIA AT
<37 WEEKS GESTATION CONT..
• Do not give diuretics
• If diastolic BP decreases to normal, may send
woman home to rest
• If there are signs of growth restriction,
consider early delivery
• If urine protein level increases, manage as
severe pre-eclampsia
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12. MANAGEMENT OF MILD PRE-ECLAMPSIA AT >37
WEEKS GESTATION
• If there are signs of fetal compromise(decreased
amniotic fluid, growth restriction)assess the
cervix and expedite deilvery.
• If the cervix is favourable: induce/augment
labour with oxytocin or rupture membrane
• If the cerix is unfavourable: ripen the cervix
with prostaglandin or delivery by caesarian
delivery
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13. MANAGEMENT OF SEVERE PRE-ECLAMPSIA
• If diastolic BP >110, give antihypertensive drugs to
decrease to 90-100 range (NOT BELOW) and start Mag
sulphate
• Start IV line
• Maintain strict fluid balance chart
• Catheterize bladder if necessary to monitor urine output
• If urine output <30cc/hour
• Withhold Mag sulphate and infuse IV fluid slowly
(1L in 8 hours)
• Monitor carefully for development of heart failure or
pulmonary edema
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14. •All cases of severe preeclampsia should
be managed actively and delivery should
occur within 24 hours of the onset of
symptoms
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MANAGEMENT OF SEVERE PRE-
ECLAMPSIA CONT..

15. ECLAMPSIA
 Diastolic BP more than 110 mm Hg after 20 weeks
gestation (though a small percentage, < 20%, of
women with eclampsia will have normal BP)
 CONVULSIONS without a previously known seizure
disorder
 Proteinuria 2+ or more
 A small proportion of women with eclampsia have
normal blood pressure
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16. DIFFERENTIAL DIAGNOSIS OF
ECLAMPSIA
•Epilepsy
•Uncomplicated Malaria
•Meningitis/Encephalitis
•Migraine
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17. STRATEGIES FOR PREVENTING ECLAMPSIA
• Antenatal care and
recognition of
hypertension
• Identification and
treatment of pre-
eclampsia by skilled
attendant
• Timely delivery
• 3.4% of women with
severe pre-eclampsia
will have a convulsion
• Eclampsia is the
number one cause of
in-hospital maternal
death in Nepal
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18. INITIALASSESSMENT AND MANAGEMENT OF
ECLAMPSIA
• Shout for help - mobilize personnel
• Rapidly evaluate breathing and state of consciousness
• Check airway, blood pressure and pulse
• Position on left side
• Protect from injury but do not restrain
• Start IV infusion with large bore needle (16-gauge)
• Give oxygen at 4 L/minute
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19. MANAGEMENT DURING A SEIZURE
 Give anticonvulsive drugs - MAG SULPHATE
FIRST CHOICE !!!
 Give oxygen at 4L - 6L/min
 Protect woman from injury but do not restrain
 Place woman on left side
 After seizure, be certain airway is clear
 Maintain calm, peaceful atmosphere
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20.  Monitor vitals signs reflexes and fetal heart rate
hourly.
 If Diastolic blood pressure remains above
110mmHg, give antihypertensive drugs,aiming ti
reduce diastolic blood pressure to less than
100mmHg but not below 90mmHg
 Catheterize the bladder to monitor output and
proteinuria
 Strict I/O charting
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MANAGEMENT DURING A SEIZURE

21. IF URINE OUTPUT IS < 30ML PER HOUR
 Withhold magnesium sulfate and infuse IV
fluid(NS/RL) at 1 L in 8 hours
 Monitor for the development of pulmonary edema
 Never leave the woman alone
 Auscultate lung bases to rule out pulmonary
edema. If rales are heard stop fluid and frusemide
40 mg IV stat
 Do bed site clotting test.Failure to form clot after 7
mins suggests coagulopathy
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22. POST CONVULSION MANAGEMENT
•Prevent further convulsions
•Control blood pressure
•Prepare for delivery (if
undelivered)
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23. ANTIHYPERTENSIVE DRUGS
• Hydralazine
• Labetolol
• Nifedipine
Principles:
• Initiate
antihypertensives if
diastolic blood pressure
> 110 mm Hg
• Maintain diastolic
blood pressure 90-100
mm Hg to prevent
cerebral hemorrhage
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24. ANTIHYPERTENSIVE DRUG DOSES
• Hydralazine: 5 mg IV slowly every five minutes
until diastolic BP in 90-100 range. Repeat hourly if
needed, or 12.5 mg every 2 hours as needed.
• Labetolol: 10mg IV. If diastolic BP remains above
110 after 10 min, give 20mg IV. May increase to
40mg and then 80mg IV every ten min until BP is
controlled in the 90-100 mm Hg range
• Nifedipine: 5mg oraly. If BP remains above 110
mm Hg after 10 min, give an additional 5 mg
orally.
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25. MANAGEMENT DURING A CONVULSION
•Give magnesium sulfate
•Gather emergency equipment (O2, mask,
etc)
•Position on left side
•Protect from injury but do not restrain
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DO NOT LEAVE THE WOMAN UNATTENDED

26. Anticonvulsive Drugs
• Magnesium sulfate
• Diazepam
• Phenytoin, Dilantin and Phenobarbitone are NOT
appropriate in the treatment of eclampsia
• Phenytoin
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MANAGEMENT DURING A CONVULSION

27. MAGNESIUM SULFATE
• Use Magnesium sulfate in women with:
• Eclampsia
• Severe pre-eclampsia necessitating delivery
• Start magnesium sulfate when decision for delivery is
made
• Continue therapy until 24 hours after delivery or the
last convulsion, whichever occurs last
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29. MAGNESIUM SULFATE LOADING DOSE
• Give magnesium sulphate 4g IV slowly over
five minutes
• Follow promptly with magnesium sulphate 10 g
(5 g in each buttocks) deep IM injection
• If convulsions recur after 15 min, give
additional 2 g IV over 5 min
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30. MAGNESIUM SULFATE MAINTENANCE DOSE
• IM - 5 g deep IM injection every 4 hours in alternating
buttocks
• Continue treatment with Mag sulphate for 24 hours
after delivery or after last seizure
• Note: If 50% solution is not available give 20% IV - 1
g slowly over 5 min every hour
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31. ADVANTAGES OF MAGNESIUM SULFATE
• It acts as an anticonvulsant
• It can be given IM or IV
• If given in appropriate doses, it does not sedate the patient
• If given in appropriate doses, it does not affect the fetus
• It is inexpensive and on the W.H.O. Essential Drugs List
• It is metabolized by the kidney and therefore does not
exacerbate liver problems that are often associated with
severe eclampsia
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32. GUIDELINES FOR ADMINISTRATION OF
MAGNESIUM SULFATE:
• Withhold magnesium sulphate temporarily if:
• Respiratory rate <16/min
• Patellar reflexes are absent
• Urine output <30cc/hour during preceeding four hours
• If a woman is unarousable or in case of arrest:
• Assist ventilation with bag/mask
• Give calcium gluconate (1g or 10cc of 10% solution IV
slowly over 5 minutes
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33. POST-CONVULSION MANAGEMENT
•Prevent further convulsions
•Control blood pressure
•Prepare for delivery (if
undelivered)
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34. MANAGEMENT
• Assess cervix
• If cervix is favorable, rupture the membranes and
induce labor using oxytocin
• Deliver by caeserian section if
• Vaginal delivery not anticipated within 12 hours for
eclampsia or 24 hours for severe pre-eclampsia
• Cervix not favorable
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35. CHILD BIRTH CONT..
•If safe anaesthesia is not available for
caeserian section or if the fetus is dead or
too premature for survival can be referred
or
• Ripen cervix (with foley catheter bulb)
• Attempt vaginal delivery with oxytocin
induction
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36. PRINCIPLES OF MANAGEMENT
• Timing and route of delivery: condition of mother vs.
maturity of fetus
• Assessment of fetus: evidence of fetal compromise
• Control of convulsions
• Control of hypertension
• Referral due to other organ complications: pulmonary, renal,
central nervous system
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37. POSTPARTUM CARE
• Anticonvulsant therapy should be maintained for 24
hours after delivery, or until last convulsion,
whichever occurs last
• Continue antihypertensive therapy as long as diastolic
BP >110
• Continue to monitor urine output
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38. REFERRAL CEONC SITE
•Consider referral of woman who has
• Oligiuria which persists for 48 hours after
childbirth
• Signs of disseminated intravascular
coagulopathy
• Persistant coma after seizure or recurrent
seizures on Mag Sulphate
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39. COMPLICATIONS OF GESTATIONAL
HYPERTENSION
• Severe fetal growth restriction - expediate delivery
• Increasing drowsiness or coma - suspect cerebral hemorrhage
• Reduce BP slowly and provide supportive therapy
• Heart, kidney or liver failure - provide supportive therapy
• Disseminated Intravascular Coagulopathy - consider transfusion,
supportive therapy
• Woman is receiving IV fluids - strict fluid balance chart
• Woman with IV lines and catheter - strict infection control
measures
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40. SUMMARY
• There are many manifestations of increased blood pressure in
pregnancy
• It is not possible to predict which patients are at risk for severe
pre-eclampsia or eclampsia
• Vigilant care is needed to make the diagnosis
• Once the diagnosis is made, appropriate treatment can reduce
morbidity and mortality
• Anticonvulsants should be used, with magnesium sulfate being the
first line
• Antihypertensives should be employed as needed
• Close monitoring is needed for side effects
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41. THANK YOU
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